Provider Demographics
NPI:1063789642
Name:MCCLELLAN, MARY (MA SE)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:MA SE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WYCHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-1820
Mailing Address - Country:US
Mailing Address - Phone:908-313-0585
Mailing Address - Fax:908-789-4703
Practice Address - Street 1:1 WYCHVIEW DR
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-1820
Practice Address - Country:US
Practice Address - Phone:908-313-0585
Practice Address - Fax:908-789-4703
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-26
Last Update Date:2011-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYMA SE103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst